PROFESSIONAL ETHICS

ROYAL COMMISSION ON HUMAN RELATIONSHIPS SIR: It is to be hoped that many controversial points concerning the Report of the Royal Commission on Human Relations raised in Dr Maddison's editorial! will get an airing in your columns. May I comment that many people see such a Commission as a rather passive group observing and analysing with the aid of the many submissions made to them the "state of play" in society, and suggesting remedies or adjustments but not really directing, in any meaningful way, the future course of society or laying down a kind of blueprint for the future. Having spent some weeks now with the five volume report as bedside or coffee table reading 1 would point out that the aim of the Commissioners was far from any such passive role. They clearly selected their material very carefully and made their recommendations with the expectation that if adopted the course of society would be influenced in certain directions. If this were not so the whole exercise would have been pointless for them. What the medical profession should now be asking is why certain recommendations which will have profound effects on the lives of young people were made in the face of medical evidence which should have required very different recommendations. I refer in particular to a lowering of the age of consent, and to certain recommendations about incest. The evidence about the deleterious effects for young girls of sexual intercourse, particularly of a promiscuous kind, is surely convincing enough to warrant consideration of a raising of the age not the reverse. As regards incest, a certain complacency seems evident in the Report which is utterly incomprehensible in the light of recent reports of the disastrous psychological damage done to children and families by the practice of incest. A civilized society normally acts to protect the young and vulnerable among its members. In respect of the two groups mentioned the Commission fails in its responsibility unless you take the view that its recommendations will have no effects whatsoever in educating people concerning the accepted norms of civilized behaviour. ALLAN M. BRYSON. 135 Macquarie Street, Sydney, N.S.W. 2000.


CORRESPONDENCE
Letters should not exceed 300 words in length. Otherwise it may not be possible to find space for them.

ROYAL COMMISSION ON HUMAN
RELATIONSHIPS SIR: It is to be hoped that many controversial points concerning the Report of the Royal Commission on Human Relations raised in Dr Maddison's editorial! will get an airing in your columns. May I comment that many people see such a Commission as a rather passive group observing and analysing with the aid of the many submissions made to them the "state of play" in society, and suggesting remedies or adjustments but not really directing, in any meaningful way, the future course of society or laying down a kind of blueprint for the future.
Having spent some weeks now with the five volume report as bedside or coffee table reading 1 would point out that the aim of the Commissioners was far from any such passive role. They clearly selected their material very carefully and made their recommendations with the expectation that if adopted the course of society would be influenced in certain directions. If this were not so the whole exercise would have been pointless for them.
What the medical profession should now be asking is why certain recommendations which will have profound effects on the lives of young people were made in the face of medical evidence which should have required very different recommendations. I refer in particular to a lowering of the age of consent, and to certain recommendations about incest. The evidence about the deleterious effects for young girls of sexual intercourse, particularly of a promiscuous kind, is surely convincing enough to warrant consideration of a raising of the age not the reverse.
As regards incest, a certain complacency seems evident in the Report which is utterly incomprehensible in the light of recent reports of the disastrous psychological damage done to children and families by the practice of incest. A civilized society normally acts to protect the young and vulnerable among its members. In respect of the two groups mentioned the Commission fails in its responsibility unless you take the view that its recommendations will have no effects whatsoever in educating people concerning the accepted norms of civilized behaviour. NUTRITIONAL PROBLEMS IN THE AUSTRALIAN COMMUNITY SIR: It is really not surprising that a reporl by a Working Party appointed in 1974 which was produced in 1978 would have a somewhat diminished impact. I The reporl is certainly a complete one and valuable, but the passage of time in relation to the essential recommendations has limited its significance. Dr Gracey in his accompanying clinical view refers to the weakness in the teaching of nutrition in medical schools which is so patently obvious that it needs little emphasis from me.? In any case it is doubtful if doctors have the knowledge, background, and training to teach it. One has to draw a clear distinction between nutrition and dietetics. It is of the utmost importance that the experimental and practical work that has already been done by agriculturists and veterinary surgeons as well as biochemists be drawn upon. Nutrition has a wide base.
What we are really trying to talk about in nutrition and its relation to the prevention of disease is how it affects cell biology, cell membrane structure and function, enzyme function, and other complex questions of cellular biochemistry which 1 can only admit are difficult for me as a surgeon to follow and understand. The study is all the more difficult as often the biochemical and structural changes induced by deficiencies are on a time scale so separate that there is little apparent relationship.
In this context vitamins are a name or a word that must be relegated to the workbasket. They are surely just a little, albeit important, part of the whole.
It is emphasized in the recommendation of the Working Party of the National Health and Medical Research Council that multivitamin tablets should be administered to various groups, (though they were only investigating thiamine) essentially to the moderate and heavy drinker group and to alcoholics. Twenty years ago, Vallee et alii wrote concerning zinc metabolism, hepatic dysfunction, and alcoholism." He established that, in these patients, hyperzincuria is associated with low serum zinc levels and diminished hepatic zinc levels and observed that zinc administered to patients with cirrhosis appeared to correct the abnormal zinc metabolism and hepatic function.
Chvapil" recently has drawn attention to the newer aspects of the biological function of zinc, illustrating experimentally, that lipid peroxidation of biostructures of the liver cell can be induced by noxious agents and that the accumulation and rate of collagen synthesis can be inhibited by zinc. The point is that while relations of thiamine deficiency has been well made in relation to groups taking (grossly) unbalanced diets and drinking even moderately the demand of these groups for zinc is every bit as great. Zinc deficiency in these groups has been closely associated with the disturbance of: It may be as well to add that the instances of interference in patient care quoted occurred over a period of 25 to 30 years, over half of them involved close relatives and of course I acknowledge that my treatment may warrant similar interferences at times.
Stephen Dale's concern about uncomplimentary comments by doctors to friends and acquaintances are usually carried back second-hand to the attending doctor; 1 was taught early in my career never to believe that these comments were ever made by a colleague and my own experience confirms that these are usually misunderstandings on the part of the patient.
It is disturbing, though, to realize that newspapers are able to extract information from any material in medical journals and report it as a news item in the media without the permission of the editor or the author. Copyright laws apparently are so weak that no action can be taken, even when the reported item grossly misrepresents the original material. All authors and correspondents should be warned by this experience.
24 on my remarks. This is particularly unfortunate since his accounts of medical disasters obtained prominent coverage in The West Australian of March 29 and did neither the profession nor the patients any good.
One recognizes that at times both specialists and general practitioners will feel it their duty to interfere in a case where there is clear evidence of gross error or of mismanagment, and my criticism was not really directed there. The real basis of my complaint was those doctors who offer gratuitous opinions and advice to their friends and acquaintances about conditions which are already being cared for adequately by those people's own practitioners. It would help professional relationships if the doctors concerned refrained from comment, or, alternatively, if they contacted the practitioner involved in the case if there was any real concern.
If Dr Orr, as his letter implies, considers my suggestions to be the counsel of perfection and perhaps a little out of reach, he will surely agree, being obviously a man of conscience, that the ideal is worth striving for. STEPHEN DALE. 96 Gugeri Street, Claremont, W.A. 6010.
SIR: Dr Orr' quotes some frightening examples in support of his argument, which presumably is: that in certain circumstances a doctor has a right to intervene in the management of another doctor's patient. I think anyone could quote cases to support their point of view whatever that point of view may be. There are many other unquoted cases which would support the opposite viewpoint. During 14 years as a part-time Commonwealth Medical Officer I have had many opportunities to point out to patients that I thought I could treat their illnesses better than their own doctor. I trust that I have learned to curb my impulsive nature. There may be cases, and probably are, when patients have benefited from interference of a doctor other than that already managing their problems, but these cases must be greatly outnumbered by the instances when such remarks simply undermine patients' confidence in their doctor, and send them to someone who has to start' from the beginning with the only result being a delay in effective treatment. There is far too much of this interference already from patients' friends and relatives. Let us as doctors do our own job as well as we can, and leave others to do theirs.

SYDNEY SQUARE DIAGNOSTIC
BREAST CLINIC SIR: In response to the need expressed by the community and by medical practitioners for better breast diagnostic services, a representative group of consultant surgeons, radiologists, pathologists and others who are particularly interested in breast disorders have set up a diagnostic breast clinic at St Andrew's House, Sydney Square, which opened in April, 1978. The purpose of the clinic is to provide consultant medical practitioners who will investigate patients previously identified by their referring doctor as having a breast problem. It is not for the routine examination of asymptomatic women. Patients will make a single visit to the clinic, and a comprehensive diagnostic report and opinion based on multiple modalities such as mammography, ultrasonography, fine needle cytology and specialist clinical examination will be returned to the referring doctor. No treatment, apart from diagnostic find needle aspiration, will be carried out at the clinic.
Each patient will be charged a fee for attendance at the clinic, the greater part of which will be refunded by Medibank or the Health Funds.
The clinic is controlled by a Medical Management Committee comprising surgeons, radiologists, pathologists, and general practitioners. Consultant surgeons and radiologists will staff the clinic on a sessional basis so as to streamline the diagnostic process and modify it to suit the requirements of each individual patient.
Since the clinic is regarded as a service to the community and to the profession, and as a research programme, the consultants will remain anonymous.
All correspondence and inquiries will be dealt with through the Medical Director who is not in private practice.

ROADSIDE RESUSCITATION
SIR: In his article "Roadside resuscitation: A simple kit" Dr Brearley presents a convincing argument for why doctors should carry well organized equipment in the boots of their cars. It is well known that many doctors who fortuitously happen to be at the scene of a road accident are hampered in managing a severely injured patient because of the lack of suitable emergency equipment.
However, I cannot agree that Dr Brearley's choice of the Air Viva as the means of providing supportive ventilation is a good one as it is now well recognized that severely injured patients require oxygen administration to reduce the subsequent threat of morbidity and mortality.' Also, the patients who are most likely to survive after a severe injury are those who are still breathing and in this regard the Air Viva is unsatisfactory. There are now several compact resuscitation kits' which are designed to administer IOO~~oxygen to breathing and non-breathing patients and which have been described in another paper. J However, the important issue stated by Dr Brearley is that doctors have a responsibility to assist at the site of a road accident and this cannot be done unless they have emergency equipment available to provide oxygen, suction, intravenous fluids, and endotracheal intubation.
DAVID ASTHMA IN MELBOURNE CHILDREN SIR: In the last weeks of February, 1978, an outbreak of asthma in children in the Melbourne metropolitan area was widely reported in the media. ' There was speculation on the contribution of aeroallergens to this outbreak.
For the last three years we have been monitoring the levels of pollen and fungal spores in the atmosphere of Melbourne' and relation of these to asthma in childhood. J During the first weeks of February, a spore trap sited at Dandenong District Hospital recorded a dramatic increase in fungal spores which preceded an increase in the incidence of asthma attendance at that Hospital's